Model could work
http://www.100md.com
《英国医生杂志》
1 NHS Confederation, London SW1E 5ER nigel.edwards@nhsconfed.org
Degeling and colleagues provide an excellent case study of how an activity designed to help improve the quality and safety of health care runs the risk of being seen as an unhelpful managerial imposition.1 The reasons why this has happened and the possible responses to it provide some important insights into the more general project of improving the NHS.
One of the biggest problems in many healthcare systems is the gulf between the front line clinical staff and policymakers and managers. In most organisations a strong link exists between the top of the organisation and the front line, and commands issued at the centre will generally be understood and implemented. In health care, however, the hierarchy is often disconnected, resulting in two separate discussions—one for policy makers, managers, and politicians about their aspirations and interests and a second for clinicians about their work. Both are legitimate, but problems arise because these two fail to connect or interact dysfunctionally. Matters are often made worse by the use of jargon and language that alienates front line staff because it is often rather abstract and does not relate to the realities of their work.
The understanding of this disconnection has led, over the past few years, to a great deal of discussion about how to "engage" clinicians in reform. Unfortunately, this carries the strong suggestion that reform, clinical governance, and other proposed improvements are an externally imposed intervention consisting of time limited projects separate from the everyday life of clinicians. Degeling and colleagues propose an approach to this problem that redefines clinical governance as an integral part of everyday work and is expressed in terms that relate to the improvement of patient care. This seems much more likely to motivate doctors.
Their proposal to make clinical governance more clinically relevant is almost certainly applicable to the wider goal of improving the NHS. Reform tends to be seen in terms of an attack on professional autonomy and as forcing reluctant clinicians to adopt a new agenda. In contrast, the approach suggested here is that reform can be achieved by working with the grain of professional practice.
There are several preconditions for the success of this model. Firstly, it needs a recognition that the definition of professionalism includes using techniques to improve the safety and effectiveness of care, to standardise it where appropriate, to take responsibility for the financial resources required, and be accountable for quality and performance. These may seem inimical to the notion of professional autonomy, but paradoxically these measures are probably required to preserve it because they permit a transparent and defensible account of practice, including decisions not to adhere to guidelines. The second is that policy makers and leaders develop objectives and ways of working that are meaningful to clinicians, are supported by performance management and appraisal systems, and help them do their work more effectively. The alternative is imposed targets and ways of managing health services that create opposition, alienation, and ultimately a failure to change that could prove terminal.
Competing interests: None declared.
References
Degeling PJ, Maxwell S, Iedema R, Hunter DJ. Making clinical governance work. BMJ 2004;329: 679-82.(Nigel Edwards, policy dir)
Degeling and colleagues provide an excellent case study of how an activity designed to help improve the quality and safety of health care runs the risk of being seen as an unhelpful managerial imposition.1 The reasons why this has happened and the possible responses to it provide some important insights into the more general project of improving the NHS.
One of the biggest problems in many healthcare systems is the gulf between the front line clinical staff and policymakers and managers. In most organisations a strong link exists between the top of the organisation and the front line, and commands issued at the centre will generally be understood and implemented. In health care, however, the hierarchy is often disconnected, resulting in two separate discussions—one for policy makers, managers, and politicians about their aspirations and interests and a second for clinicians about their work. Both are legitimate, but problems arise because these two fail to connect or interact dysfunctionally. Matters are often made worse by the use of jargon and language that alienates front line staff because it is often rather abstract and does not relate to the realities of their work.
The understanding of this disconnection has led, over the past few years, to a great deal of discussion about how to "engage" clinicians in reform. Unfortunately, this carries the strong suggestion that reform, clinical governance, and other proposed improvements are an externally imposed intervention consisting of time limited projects separate from the everyday life of clinicians. Degeling and colleagues propose an approach to this problem that redefines clinical governance as an integral part of everyday work and is expressed in terms that relate to the improvement of patient care. This seems much more likely to motivate doctors.
Their proposal to make clinical governance more clinically relevant is almost certainly applicable to the wider goal of improving the NHS. Reform tends to be seen in terms of an attack on professional autonomy and as forcing reluctant clinicians to adopt a new agenda. In contrast, the approach suggested here is that reform can be achieved by working with the grain of professional practice.
There are several preconditions for the success of this model. Firstly, it needs a recognition that the definition of professionalism includes using techniques to improve the safety and effectiveness of care, to standardise it where appropriate, to take responsibility for the financial resources required, and be accountable for quality and performance. These may seem inimical to the notion of professional autonomy, but paradoxically these measures are probably required to preserve it because they permit a transparent and defensible account of practice, including decisions not to adhere to guidelines. The second is that policy makers and leaders develop objectives and ways of working that are meaningful to clinicians, are supported by performance management and appraisal systems, and help them do their work more effectively. The alternative is imposed targets and ways of managing health services that create opposition, alienation, and ultimately a failure to change that could prove terminal.
Competing interests: None declared.
References
Degeling PJ, Maxwell S, Iedema R, Hunter DJ. Making clinical governance work. BMJ 2004;329: 679-82.(Nigel Edwards, policy dir)